North East Catchment Diabetes Referral Form

NORTH EAST CATCHMENT DIABETES REFERRAL FORM

Referring To:
<AdrDetails>
Date of referral: <FormattedDate>

Austin Health / Fax: 9496 4337 or Urgent: 9496 3234 / Phone: 9496 2211 or Urgent:9496 5000
Banyule Community Health / Fax: 9450 2662 / Phone 9450 2000
Darebin Community Health / Fax: 8470 1107 / Phone: 8470 1111
Nillumbik Health / Fax: 9431 0339 / Phone: 9430 9100

To manage referrals more efficiently, your referral may be redirected when necessary to one of the above partner agencies. (This will occur with notification and feedback to you).

Part A: PATIENT DETAILS

Name of patient:
<PtName> / Referring GP:
<DrName>
DOB: <PtDoB> / Name of Practice:
<Practice>
Address:
<PtAddress> / Practice Phone:
<UsrPhone>
Practice Fax:
<UsrFax>
Interpreter required:
<Interpreter required> / If interpreter required:
Language spoken <Language spoken?>
Home telephone:
<PtPhoneH>
Mobile:
<PtPhoneMob>

In order to triage and process the referral appropriately and for comprehensive assessment and management of the patient/client, we require the following information to be forwarded:

Reason for Referral:
<Reason for referral?>
Diabetes History:
<Type of Diabetes?>
<Visits>
Other History:
<Other History?>
Is the patient seeing an Endocrinologist <Is the patient seeing an Endocrinologist?>
If yes, Contact details of Endocrinologist.<Contact details of Endocrinologist?>
Current Medications:
<CurrentRx>
Investigation Results: - Please include the following (<3 months old):
HbA1c (within last 3 months), U&Es including eGFR, Fasting Glucose/OGTT, Fasting Lipid Profile (TC, Trig, HDL, LDL,Ratio), LFTs, FBE and Urine - Micro albumin/ACR:
<Ix>

Reason for Referral- essential information

Diabetes related problems (Reason for referral)
Acutely elevated blood glucose > 20 mmol/L / <Acutely elevated blood glucose > 20 mmol/L >
Recurrent hypoglycaemia / <Recurrent hypoglycaemia?>
Active foot ulcer or wound / <Active foot ulcer or wound?>
Recent Diabetic Ketoacidosis (DKA) / <Recent Diabetic Ketoacidosis (DKA)>
Recent Hyperosmolar Hyperglycaemic State (HHS) / <Recent Hyperosmolar Hyperglycemic State (HHS) ?>
LADA for insulin commencement / <LADA for insulin commencement >
Triglycerides >11.2mmol/L / <Triglycerides >11.2mmol/L>
Commence insulin / <Commence insulin?>
T2DM requiring insulin or GLP-1 initiation or titration / <T2DM requiring insulin or GLP-1 initiation or titration?>
eGFR <45 (mL/min/ 1.73m2) / <eGFR <45 (mL/min/ 1.73m2)>
On corticosteroids (prednisolone and dexamethasone) regardless of HbA1c / <On corticosteroids (prednisolone and dexamethaso>
Requiring insulin titration / <Requiring insulin titration?>
Pre diabetes / <Pre diabetes?>
New diagnosis / <New diagnosis>

Diabetes- related hospital admission within the last 12 months: <Diabetes related admission last 12/12?>

Details for after hours emergency contact for patient:
Name: <After hours contact person for patient?>
Phone No. <After hours contact person phone no?>

The client has consented to this information being sent to <AdrName>

<Consent obtained?>

Signed: ______(Client)

Or: (Provider) ______on behalf of client (verbal consent)

*****Please ensure the below checklist is covered in your investigation results*****

DIABETES REFERRAL CHECKLIST - Your referral will be sent back for completion if checklist is not covered

HbA1C (within last 3 months) / <HbA1C (within last 3 months)?> / U&E including eGFR / <U&E including eGFR?>
Fasting Glucose/OGTT / <Fasting Glucose/OGTT> / LFTs / <LFTs>
Fasting Lipid Profile: TC, Trig, HDL, LDL, Ratio / <Fasting Lipid Profile: TC, Trig, HDL, LDL, Ratio> / FBE / <FBE>
Urine- Micro albumin/ACR / <Urine- Micro albumin/ACR?>

PART B : INJECTABLE (INSULIN/GLP-1) INITIATION/STABILISATION REQUEST

Note - Form must be signed by requesting GP for Diabetes Educators to proceed with insulin or GLP-1 initiation or stabilisation.

Could you please commence:

Insulin/GLP-1 initiation/stabilisation Request (order and regimen):

Medication / Before Breakfast Dose (Units) / Before Lunch Dose
(Units) / Before Dinner Dose
(Units) / Before Bed Dose
(Units)
<Medication Name?> / <Before breakfast dose ? Units> / <Before Lunch dose ? Units> / <Before Dinner Dose ? Units> / <Before Bed Dose ? Units>
Signature: / ______/ ______/ ______/ ______

Dose adjustment (please select yes or no):

Undertaken by GP:<Undertaken by GP?>

Enrolled patient on self-titration program:<Enrolled patient on self-titration program?>

NH Prompt Policy Insulin dose adjustment by credentialled diabetes educator:<NH Prompt Policy?>

Changes to other glucose lowering medications - please specify:

<Changes to other glucose lowering medications?>

Target/reportable levels

Fasting: <Target /reportable levels: Fasting ? mmol/L>Pre prandial: <Target/reportable levels: Pre prandial: ? mmol/L> Post prandial: <Target/reportable levels: Post prandial? mmol/L>

Dr Name:
<DrDetails>
Dr Signature:______

1